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NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION 2018 National EMS Scope of Practice Model The National Highway Traffic Safety Administration Education Certification Licensure Credentialing E M S S c o p e o f P r a c t i c e ®

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Page 1: 2018 National EMS Scope of Practice Modeldhhs.ne.gov/licensure/Documents/CREMS2018NatlEMSScopeOf...The National EMS Scope Of Practice Model September 2018 Prepublication Display Copy

NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION

2018 National EMSScope of Practice Model

The National Highway Traffic Safety Administration

Education

Certification

Licensure

Credentialing

EMSScope of Practic

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Table of Contents

Table of Contents ............................................................................................................. 1

Executive Summary ......................................................................................................... 3

I. Background .................................................................................................................... 6 Overview of the EMS Profession .............................................................................................................. 6 The Evolution of the EMS Agenda for the Future .................................................................................... 7 Implementation of the 2007 National EMS Scope of Practice Model ...................................................... 8 Approach to Revising the National EMS Scope of Practice Model ........................................................ 10 The Role of State Government ................................................................................................................ 11

II. Understanding Professional Scope Of Practice .................................................... 13 Overview ................................................................................................................................................. 13 The Interdependent Relationship Between Education, Certification, Licensure, and Credentialing ...... 14 Scope of Practice versus Standard of Care .............................................................................................. 19 A Comprehensive Approach to Safe and Effective Out of Hospital Care .............................................. 19

III. Special Considerations ............................................................................................ 20 Liability in EMS Licensing and Oversight.............................................................................................. 20 Scope of Practice for Special Populations ............................................................................................... 20 Scope of Practice During Disasters, Public Health Emergencies, and Extraordinary Circumstances .... 21 Scope of Practice for EMS Personnel Functioning in Nontraditional Roles .......................................... 21 Specialty Care Delivered by Licensed EMS Personnel .......................................................................... 21 Military to Civilian EMS Transition ....................................................................................................... 22

IV. Description of Levels................................................................................................ 24 Emergency Medical Responder (EMR) .................................................................................................. 24 Emergency Medical Technician (EMT) .................................................................................................. 25 Advanced Emergency Medical Technician (AEMT) .............................................................................. 26 Paramedic ................................................................................................................................................ 28

V. Depth and Breadth of Knowledge ............................................................................ 30

VI. Interpretive Guidelines ............................................................................................. 32 I. Skill – Airway/Ventilation/Oxygenation ............................................................................................. 32 II. Skill – Cardiovascular/Circulation ..................................................................................................... 33 III. Skill – Splinting, Spinal Motion Restriction (SMR), and Patient Restraint ...................................... 34 IV. Skill – Medication Administration – Routes ..................................................................................... 35 V. Medical Director Approved Medications ........................................................................................... 36 VI. Skill – IV Initiation/Maintenance Fluids........................................................................................... 37 VII. Skill – Miscellaneous ....................................................................................................................... 37

VII. Definitions ................................................................................................................. 39

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Table of Contents 2

Appendix I. History of Occupational Regulation in EMS .......................................... 42

Appendix II. Changes and Considerations from the 2007 Practice Model ............. 46 Nomenclature .......................................................................................................................................... 47 Academic Degree Requirements for Paramedics .................................................................................... 47 Attendant Qualifications for Ambulance Transport ................................................................................ 47 Portable Technologies ............................................................................................................................. 48 Deletions/Updates ................................................................................................................................... 48 Additions to the Interpretive Guidelines ................................................................................................. 49

Appendix III. Legal Differences Between Certification and Licensure .................... 52

Appendix IV. Acknowledgements ................................................................................ 54 Subject Matter Expert Panel .................................................................................................................... 54 Contributors ............................................................................................................................................. 56 Technical Writers .................................................................................................................................... 56 Project Manager ...................................................................................................................................... 56 Project Coordinator and Graphic Designer ............................................................................................. 56 Executive Staff ........................................................................................................................................ 56

Appendix V. References ................................................................................................ 57

This document was produced by the National Association of State EMS Officials with support from the US

Department of Transportation, National Highway Traffic Safety Administration (NHTSA), Office of Emergency

Medical Services (OEMS) through Contract DTNH2216C00026, with supplemental funding from the Health

Resources and Services Administration (HRSA) Emergency Medical Services for Children Program. The opinions,

findings and conclusions expressed in this publication are those of the authors and not necessarily those of USDOT,

NHTSA, or HRSA.

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Executive Summary 3

Executive Summary

The National EMS Scope of Practice Model (“Practice Model”) 1 is a continuation of the

commitment of the National Highway Traffic Safety Administration (NHTSA) and the Health

Resources and Services Administration (HRSA) to the implementation of the EMS Agenda for

the Future (“EMS Agenda”)2. It is part of an integrated, interdependent system, first proposed in

the EMS Education Agenda for the Future: A Systems Approach (“Education Agenda”)3 that

endeavors to maximize efficiency, consistency of instructional quality, and student competence.

It supports a system of EMS personnel licensure that is common in other allied health

professions and is a guide for States in developing their Scope of Practice legislation, rules, and

regulation.

Scope of practice—Defined parameters of various duties or services

that may be provided by an individual with specific credentials.

Whether regulated by rule, statute, or court decision, it represents the

limits of services an individual may legally perform.

Each State has the responsibility to protect the health and safety of its citizens through powers

that are granted by the 14th Amendment of the United States Constitution4. State policymakers

play a critical and longstanding role in occupational licensing policies, dating back to the late

19th century when the U. S. Supreme Court decision in Dent v. West Virginia5 established

States’ rights to regulate certain professions. Shortly after, States began developing their own

systems of occupational regulation and licensing. Most recently (2015), in North Carolina State

Board of Dental Examiners v. Federal Trade Commission6, the U.S. Supreme Court held that an

occupational licensing board has immunity from antitrust law only when it is actively supervised

by the State, reinforcing the need to maintain the regulatory hierarchy that currently serves a

variety of occupational and professional disciplines. Since the legal authority to practice can be

obtained only from the State, the State licensure process provides a means for States to pursue

unlawful practice by unlicensed individuals. This affords title protection to EMS personnel that

comply with State regulations, and protection of the public from individuals who have not met

minimum standards.

The Practice Model has been utilized as a model by States as a means to increase regulatory

uniformity in emergency medical services (EMS) for over a decade. Core to this document and

the practice of every licensed health professional is compliance with four domains intended to

serve the legal and ethical obligation of States to ensure the public is protected from unqualified

individuals:

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Executive Summary 4

While many users of the 2018 Practice Model may be more interested in the list of psychomotor

skills that appear as interpretive guidelines, this list is neither prescriptive nor finite. What is

even more important are the fundamental principles that serve any professional scope of practice

model explained throughout the document. To be clear: a licensed practitioner is not permitted to

perform any skill if they fail to conform with any of the four domains related to that particular

skill, including the demonstration of ongoing competency.

A Subject Matter Expert Panel (“Expert Panel”) was selected to revise the Practice Model in

2017. Comprised of representatives from several national EMS organizations and the EMS

public including experienced field personnel, EMS educators, EMS medical directors, EMS

agency administrators, and State EMS regulators, the Expert Panel utilized the Grades of

Recommendation Assessment, Development and Evaluation (GRADE) process to consider

evidence and establish consensus on a number of topics. When the scientific literature was

inconclusive, expert opinion was used to improve descriptions, roles, and attributes of each level

that would support changes in practice by addressing two fundamental questions:

1. Is there evidence that the procedure or skill is beneficial to public health?

2. What is the clinical evidence that the new skill or technique as used by EMS personnel

will promote access to quality health care or improve patient outcomes?

It is important to note that the Expert Panel was tasked to define entry-level expectations to

ensure a level of national consistency. In other words, the Practice Model suggests the minimum

practice requirements in advance of gaining field experience prior to supervised or individual

work experience at the levels of an Emergency Medical Responder (EMR), Emergency Medical

Technician (EMT), Advanced Emergency Medical Technician (AEMT), or Paramedic.

National EMS Program Accreditation was identified in the Education Agenda as the means to

“provide minimum program requirements for sponsorship, resources, students, operational

policies, program evaluation, and curriculum” at all EMS levels. The Commission on

Accreditation of Allied Health Education Programs (CAAHEP), the largest programmatic

accreditor in the health sciences field, currently accredits over 2200 education programs in 30

health sciences fields including 611 at the paramedic level across all 50 states. The Expert Panel

considered the evidence related to the value of National EMS Program Accreditation towards

student and patient outcomes and encourages collaboration among stakeholder groups for full

implementation of national EMS program accreditation at the AEMT level by 2025.

An individual may only perform a skill or role for which that person is:

EDUCATED (has been trained to perform the skill or role), AND

CERTIFIED (has demonstrated competence in the skill or role), AND

LICENSED (has legal authority issued by the State to perform the skill or role), AND

CREDENTIALED (has been authorized by medical director to perform the skill or role).

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Executive Summary 5

Finally, the U.S. is transforming its health care system to provide quality care leading to

improved health outcomes achieved through interdisciplinary collaboration. EMS personnel are

key to this transformation through innovative approaches in a variety of practice settings. The

Expert Panel strongly supports the national call for the elimination of barriers for all professions

to practice to the full extent of their education, training, and competence with a focus on

collaborative teamwork to maximize and improve care throughout the health care system7.

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I. Background 6

I. Background

Overview of the EMS Profession

The Practice Model provides a resource for defining the practice of Emergency Medical Services

(EMS) personnel. EMS clinicians are unique health care professionals in that they provide

medical care in many environments, locations, and situations. Much of this care occurs in out of

hospital settings with little onsite supervision. Physician medical directors provide medical

oversight to ensure and maintain safe EMS practices. This is occasionally performed in-person

by medical directors in the field or through electronic communications, but more commonly is

accomplished through protocol development and quality improvement based on evidence-based

treatment standards and resources such as this Practice Model. EMS personnel are not

independent clinicians, but are expected to execute many treatment modalities based on their

assessments and protocols in challenging situations. They must be able to exercise considerable

judgment, problem-solving, and decision-making skills.

In the vast majority of communities, residents call for EMS by dialing 9-1-1 when they need

emergency medical care, and the appropriate resources are dispatched. EMS personnel respond

and provide care to the patient in the setting in which the patient became ill or injured, including

the home, field, recreational, work, and industrial settings. Many of these are in high-risk

situations, such as on highways and freeways, violent scenarios, and other unique settings.

Many EMS personnel provide medical transportation services for patients requiring medical care

while enroute to or between medical facilities, in both ground and air ambulance entities. These

transport situations may originate from emergency scenes, or may be scheduled transports

moving patients from one licensed facility to another. The complexity of care delivered by

EMS personnel can range from very basic skills to exceptionally complex monitoring and

interventions for very high acuity patients.

Medical care at mass gatherings (e.g., concerts or sporting events) and high-risk activities (e.g.,

fireground operations, or law enforcement tactical operations) are a growing expectation of EMS

personnel. EMS personnel sometimes serve in an emergency response or primary care role

combined with an occupational setting in remote areas (e.g., off-shore oil rigs and wildland

fires). EMS personnel also work in more traditional health care settings in hospitals, urgent care

centers, doctor’s offices and long-term care facilities. Finally, EMS personnel are involved in

numerous community and public health initiatives, such as working with health care systems to

provide non-emergent care and follow up to certain patient populations as well as providing

immunizations, illness and injury prevention programs, and other health initiatives.

EMS is a local function and organized in a variety of ways. These include agencies that are

volunteer, career, or a combination; agencies that are operated by government, health care

system, or private entities; and agencies that are stand-alone EMS, fire-based or law

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I. Background 7

enforcement-based. Common models are municipal government (fire-based or third-service) or a

contracted service with a private (profit or nonprofit) entity. Multiple levels of licensure exist for

EMS personnel, each offering different levels of scopes of practice. EMS personnel provide

medical care to those with emergent, urgent, and in some cases chronic medical needs. EMS is a

component of the overall health care system, and delivers care as part of a system intended to

reduce the morbidity and mortality associated with illness and injury. EMS care is enhanced

through the linking with other community health resources and integration within the health care

system.

The Evolution of the EMS Agenda for the Future

The original Practice Model was developed in 2007 as one part of the NHTSA’s commitment to

its EMS Agenda. Released in 1996, the EMS Agenda established a long-term vision for the future

of EMS in the United States:

“EMS of the future will be community-based health management that is fully

integrated with the overall health care system. It will have the ability to identify

and modify illness and injury risks, provide acute illness and injury care and

follow up, and contribute to treatment of chronic conditions and community

health monitoring. This new entity will be developed from redistribution of

existing health care resources and it will be integrated with other health care

professionals and public health and safety agencies. It will improve community

health and result in a more appropriate use of acute health care resources. EMS

will remain the public’s emergency medical safety net.”

A process to update the EMS Agenda is underway (http://emsagenda2050.org/).

As a follow up to the EMS Agenda, the Education Agenda, released in 2000, called for the

development of a system to support the education, certification and licensure of entry-level EMS

personnel that facilitates national consistency:

“The Education Agenda established a vision for the future of EMS education, and

called for an improved structured system to educate the next generation of EMS

personnel. The Education Agenda built on broad concepts from the 1996 Agenda

to create a vision for an educational system that will result in improved efficiency

for the national EMS education process. This was to enhance consistency in

education quality ultimately leading to greater entry-level graduate competence.”

The Education Agenda proposed an EMS education system with five integrated components:

National EMS Core Content, National EMS Scope of Practice Model, National EMS Education

Standards, National EMS Certification, and National EMS Education Program Accreditation.

The National EMS Core Content8, released in 2004, defined the domain of out of hospital care.

The 2007 Practice Model divided the core content into levels of practice, defining the minimum

corresponding skills and knowledge for each level. Our nation has made great progress in

implementing these documents over the preceding decade.

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I. Background 8

Several forces have combined to revise the Practice Model:

1. As States have widely implemented the Practice Model, many have chosen to add skills

to their authorized scopes of practice beyond the floor called for in the national model.

2. EMS research is providing new evidence about the effectiveness of interventions in the

out of hospital setting.

3. Our nation is facing new health problems including explosive growth in opiate abuse,

threats of violence and terrorism, and new challenges related to a growing population

over the age of 65.

4. The National EMS Information System (NEMSIS) is maturing to provide information

about what levels of EMS personnel are performing which skills and interventions.

The development and publication of the Practice Model represents a transition from the

historical connection between scope of practice and the EMS National Standard Curricula. The

Practice Model is a consensus document, guided by data and expert opinion that reflects the

skills representing the minimum competencies of the levels of EMS personnel.

This update of the Practice Model is a natural and expected activity in assuring that our EMS

personnel are prepared to meet the needs and expectations of the communities they serve.

Implementation of the 2007 National EMS Scope of Practice Model

EMS crews today are better equipped than ever for the worst kinds of emergencies, from cardiac

arrests and gunshot victims to car crashes and other life-threatening emergencies. In its “Future

of Emergency Care” series, the National Academies of Science, Engineering, and Medicine

(formerly known as the Institute of Medicine) envisioned high integration of the emergency and

trauma care systems to function effectively. “Operationally,” said the NASEM, “this means that

all of the key players in a given region...must work together to make decisions, deploy resources,

and monitor and adjust system operations based on performance feedback9.”

A system that attracted a generation of emergency care personnel depicted in the popular 1970’s

television series, “Emergency,” is now faced with the realities of providing care in a fragmented

health care system with limited resources, overcrowded emergency departments, inadequate

mental health resources, a nationwide opioid epidemic, escalating domestic and street violence,

hazardous material risks and exposures, high consequence infectious disease, an aging

population with complex needs, increasing threats from terrorism and other mass casualty events

that require 24/7 operational readiness along with constant non-urgent social, medical, and

transport requests that were not fully contemplated in the 2007 Practice Model. These competing

concerns illustrate a crucial need to find innovative strategies to improve EMS care delivery

inside and outside the boundaries of an ambulance. The licensure of EMS personnel, like that of

other health care licensure systems, is part of an integrated and comprehensive system to

improve patient care and safety and to protect the public. The challenge facing the EMS

community including regulators is to develop a system that establishes national standards for

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I. Background 9

personnel licensure and their minimum competencies while remaining flexible enough to meet

the unique needs of State and local jurisdictions.

According to the 2011 National EMS Assessment10, 826,111 licensed EMS personnel encounter

nearly 37 million patients a year in the United States and reflect a multi-billion dollar enterprise.

Implementing the 2007 Practice Model required consideration of funding, reimbursement,

transition courses, grandfathering of current personnel, development of educational and

instructional support materials, workforce issues, labor negotiations, impact on volunteerism, and

other important issues. The majority of States required legislative and rulemaking changes but

the effort resulted in four nationally recognized levels of EMS clinicians as described by the

2007 Practice Model compared to at least 44 different levels of EMS personnel certification

reported in the United States in 1996.

According to data collected by NASEMSO in 201311, 100% of States use the Practice Model as

the minimum allowable psychomotor skill set at the EMT and paramedic levels. 76% of States

are using the Practice Model as the minimum allowable psychomotor skill set at the EMR level

and 88% of States are using the Practice Model as the minimum allowable psychomotor skill set

at the AEMT level. Several States have completed the transition of the Intermediate-85 level to

AEMT. In December 2017, the National Registry of Emergency Medical Technicians (NREMT)

announced plans to permanently retire the Intermediate-99 exam currently being used by a

handful of States as a State assessment exam. The effective date for this transition to be complete

is December 31, 2019.

According to data collected by NASEMSO in 2014, 90% of States effectively require National

EMS Program Accreditation at the Paramedic level.

As of March 31, 2018, CAAHEP lists accredited EMS programs at the paramedic level in all 50

States. 611 paramedic programs have successfully completed the accreditation process and are

fully accredited, a 92% increase in the number of nationally accredited paramedic programs from

2007. Another 78 paramedic programs hold a Letter of Review (LoR) from the Committee on

Accreditation of Educational Programs for the Emergency Medical Services Professions

(CoAEMSP), meaning that they are actively engaged in the accreditation process.

According to real time data12 available from the NREMT:

• 23 States and the District of Columbia require National EMS Certification as a basis for

initial State licensure at the EMR level. An additional 4 States utilize National EMS

Certification as an optional or alternate entry process at the EMR level. 22 States do not

license EMRs.

• 42 States and the District of Columbia require National EMS Certification as a basis for

initial State licensure at the EMT level. An additional 4 States utilize National EMS

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I. Background 10

Certification as an optional or alternate entry process at the EMT level. 4 States maintain

a State-based or combination process for certification and licensure at this level.

• 36 States and the District of Columbia require National EMS Certification as a basis for

initial State licensure at the AEMT level. An additional 4 States utilize National EMS

Certification as an optional or alternate entry process at the AEMT level. 10 States do

not license AEMT’s.

• 45 States and the District of Columbia require National EMS Certification as a basis for

initial State licensure at the paramedic level. An additional 3 States utilize National EMS

Certification as an optional or alternate entry process at the paramedic level. 2 States

maintain a State-based process for certification and licensure at this level.

Approach to Revising the National EMS Scope of Practice Model

Since the original 2007 Practice Model document, the evidence for which interventions and

treatments are useful and effective in an EMS setting has expanded significantly. Similarly,

growing interest in EMS research is putting a sharper focus on how specific interventions are

affecting the care and outcomes of patients in the out of hospital setting.

This 2018 document makes use of a Patient, Population, or Problem, Intervention, Comparison,

and Outcome (PICO) Model to examine five clinical topics relevant to EMS treatment. The

topics were selected for a systematic review of literature for consideration as high priority issues

requiring analysis due to the frequency or need of the interventions being provided at different

levels from the 2007 Practice Model in some States. These are:

1. Use of opioid antagonists by all levels of EMS personnel

2. Therapeutic hypothermia in cardiac arrest (i.e. Targeted temperature management)

3. Pharmacological pain management following an acute traumatic event

4. Hemorrhage control (i.e tourniquets and hemostatic dressings)

5. CPAP/BiPAP at the EMT level

Two limitations on using evidence to establish an EMS scope of practice are:

1. While evidence may tell us what is or is not effective, it generally does not suggest what

level(s) of EMS personnel are appropriate to perform a specific intervention, and;

2. There are still limitations on the evidence for much of what is included in an EMS scope

of practice.

Several suggestions were received during the national revision process to increase the EMS

scope of practice at all levels. To address each of these suggestions, therapeutic benefits to the

overall patient care and expected clinical outcomes were considered with the level of risk to

patients, the economic burdens of additional hours of education, requirements to maintain

competency, and level of supervision needed to complete the task/skill. Clinical acts that were

viewed by the Expert Panel to require experience and additional training beyond the basic

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I. Background 11

education program required for licensure while not providing significant measurable benefit

were not adopted as a national model. States following the Practice Model as closely as possible

will increase the consistency of the nomenclature and competencies of EMS personnel

nationwide, facilitate reciprocity, improve professional mobility and enhance the name

recognition and public understanding of EMS. (See Appendix II: Changes and Considerations

from the 2007 Practice Model.)

The administration of an opioid antagonist and hemorrhage control including tourniquets and

wound packing were considered urgent and a change notice to add these skills at all levels was

promulgated by NHTSA in 201713.

As the 2018 National EMS Scope of Practice Model has been developed it has relied upon

extensive literature review, systematic analysis of policy documents regarding health care

licensing and patient safety, the input of an Expert Panel, and extensive public input.

Analysis and research on patient safety, scope of practice, and EMS personnel competency must

remain a priority among the leadership of national associations, Federal agencies, and research

institutions. When EMS data collection, subsequent analysis, and scientific conclusions are

published and replicated, later versions of the Practice Model should be driven by those findings.

The Role of State Government

Each State has the statutory authority and responsibility to regulate EMS within its borders and

to determine the scope of practice of State-licensed EMS personnel. The Practice Model is a

consensus-based document that was developed to improve the consistency of EMS personnel

licensure levels and nomenclature among States; it does not have regulatory influence unless

adopted by the State. However, the widespread use and adoption of the Practice Model suggests

that it represents an accepted national standard. Any state that adopts a scope of practice that

significantly deviates below or above this national model should be guided by a collaborative

process that analyzes the potential benefit, safety risks, costs and required training that are

specific to the structure of the EMS system within the State.

The Practice Model identifies the psychomotor skills and knowledge necessary for the minimum

competence of each nationally identified level of EMS personnel. This competence is assured by

completion of a nationally accredited educational program and national certification. This model

will be used to revise the National EMS Education Standards 14, national EMS certification

exams, and national EMS educational program accreditation. Under this model, to be eligible for

State licensure, EMS personnel must be educated and verifiably competent in the minimum

cognitive, affective, and psychomotor skills needed to ensure safe and effective practice at that

level. Eligibility to practice is dependent on education, certification, State licensure, and

credentialing by the physician medical director.

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I. Background 12

While each State has the right to establish its own levels of EMS personnel and their scopes of

practice, staying as close to this model as possible, and especially not going below it for any

level, will facilitate reciprocity, standardize professional recognition, and decrease the necessity

of each State developing its own education and certification materials. The Education Standards,

national certification, national educational program accreditation, and publisher-developed

instructional support material provide States with essential infrastructure support for each

nationally defined EMS licensure level.

Some States permit licensed EMS personnel to perform skills and roles beyond the minimum

skill set as they gain knowledge, additional education, experience, and (possibly) additional

certification (See also Section III Specialty Care Delivered by Licensed EMS Personnel.) Care

must be taken to consider the level of cognition and critical thinking necessary to perform a skill

safely. For instance, some skills may be simple to perform, but require considerable clinical

judgment to know when they should, and should not, be performed.

The Practice Model will continue to serve EMS in the future as it is revised and updated to

include changes in medical science, new technology, and research findings.

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II. Understanding Professional Scope Of Practice 13

II. Understanding Professional Scope Of Practice

Overview

“Scope of practice” is a legal description of the distinction between licensed health care

personnel and the lay public and among different licensed health care professionals. It describes

the authority vested by a State in individuals that are licensed within that State. In general,

scopes of practice focus on activities that are regulated by law (for example, starting an

intravenous line, administering a medication, etc.). This includes technical skills that, if done

improperly, represent a significant hazard to the patient and therefore must be regulated for

public protection. Scope of practice establishes which activities and procedures that would

represent illegal activity if performed without a license and restricts the use of professional titles

to persons that are authorized by the state. In addition to drawing the boundaries between the

professionals and the layperson, scope of practice also defines the boundaries among

professionals, creating either exclusive or overlapping domains of practice.

Scope of Practice is a description of what a licensed individual legally

can, and cannot, do.

This Practice Model should be used by the States to develop scope of practice legislation, rules,

and regulation. The specific mechanism that each State uses to define the State’s scope of

practice for EMS personnel varies. State scopes of practice may be more specific than those

included in this model and may specifically identify both the minimum and maximum skills and

roles of each level of EMS licensure.

Generally, changing a law is more difficult than changing a regulation;

changing a regulation is more difficult than changing a policy.

Scopes of practice are typically defined in law, regulations, and/or policy documents. Some

States include specific language within the law, regulation or policy, while others refer to a

separate document using a technique known as “incorporation by reference.” The Practice

Model provides a mechanism to implement comparable EMS scopes of practice between States.

Scopes of practice need not define every activity of a licensed individual (for example, lifting

and moving patients, taking a blood pressure, direct pressure for bleeding control, etc.). The

Practice Model includes suggested verbiage for the State scopes of practice in the section

entitled “EMS Personnel Scopes of Practice.” The interpretive guidelines include a more detailed

list of skills discussed by the Expert Panel. These skills, which generally should not appear in

scope of practice regulatory documents, are included to provide the user with greater insight as to

the deliberations and discussion of the group and are not intended to serve as a comprehensive

list of permitted skills.

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II. Understanding Professional Scope Of Practice 14

The Interdependent Relationship Between Education, Certification,

Licensure, and Credentialing

The Practice Model establishes a framework that ultimately determines the range of skills and

roles that an individual possessing a State EMS license is authorized to do on a given day, in a

given EMS system. It is based on the notion that education, certification, licensure, and

credentialing represent four separate but related activities.

Education includes all of the cognitive, psychomotor, and

affective learning that individuals have undergone

throughout their lives. This includes entry-level education,

continuing professional education, formal and informal

learning. Clearly, many individuals have extensive

education that in some cases exceeds their EMS skills or

roles.

Certification is an external verification of the competencies

that an individual has achieved and typically involves an

examination process. While certification exams can be set

to any level of proficiency, in health care they are typically

designed to verify that an individual has achieved

minimum competency to assure safe and effective patient

care.

Licensure represents legal authority granted to an

individual by the State to perform certain restricted

activities. Scope of practice represents the legal limits of

the licensed individual’s performance. States have a variety

of mechanisms to define the margins of what an individual

is legally permitted to perform. This authority granted by

the state is defined as licensure in this document, but some

states still use “certification” to describe the same granting

of authority to practice for EMS personnel. In these cases,

this state authority should not be confused with

certification to verify competency as described in the

preceding paragraph. Throughout this document, licensure

will refer to the authority of the State to grant an individual

the ability to practice at a certain level of EMS practitioner,

whether or not a State refers to this process as certification.

Educated toPerform

Certified asCompetent

Educated toPerform

Educated toPerform

Certified asCompetent

State Licensed to

Practice

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II. Understanding Professional Scope Of Practice 15

Credentialing is a clinical determination that is the

responsibility of a physician medical director. It is the

employer or affiliating organization’s responsibility to act

on the clinical credentialing status of EMS personnel in

making employment and deployment decisions.

For every individual, these four domains are of slightly different relative sizes. However, one

concept remains constant: an individual may only perform a skill or role for which that person is:

• educated (has been trained to perform the skill or role), AND

• certified (has demonstrated competence in the skill or role), AND

• licensed (has legal authority issued by the State to perform the skill or role), AND

• credentialed (has been authorized by medical director to perform the skill or role).

This relationship is represented graphically in Fig. 1.

Educated to

Perform

Certified as

Competent

State Licensed toPractice

Credentialed

by MedicalDirector

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II. Understanding Professional Scope Of Practice 16

Figure 1: The relationship among education, certification, licensure, and credentialing.

The center of Fig 1, where all the four elements overlap, represents skills and roles for which an

individual has been educated, certified, licensed by a State, and credentialed. This is the only

acceptable region of performance, as it entails four overlapping and mutually dependent levels of

public protection: education, certification, licensure, and credentialing. Individuals may perform

those roles and skills for which they are educated, certified, licensed, AND credentialed.

A significant risk to patient safety occurs when EMS personnel are placed into situations and

roles for which they are not experientially or educationally prepared. It is the shared

responsibility of medical oversight by a physician, clinical and administrative supervision,

regulation, and quality assurance to ensure that EMS personnel are not placed in situations where

they exceed the State’s scope of practice. For the protection of the public, regulation must assure

that EMS personnel are functioning within their scope of practice, level of education,

certification, and credentialing process. Figure 2 illustrates the interconnections among

education, certification of baseline competency, licensing by a regulating body, and credentialing

by the medical director.

An individual

may perform only

those p rocedures for

which they are

educated, certified,

licensed, and

credentialed.

Educated to

Perform

Certified as

Competent

State Licensed toPractice

Credentialed

by MedicalDirector

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II. Understanding Professional Scope Of Practice 17

Figure 2: Skill and role situations not covered by all four elements for protection of the public.

Region “A”: represents skills and roles for which an individual has received

education, but is neither certified, licensed, nor credentialed. For example, an EMT

in a paramedic class is taught paramedic level skills; despite being trained, the EMT

cannot perform those skills until such time that he is certified, licensed, and

credentialed by the Local EMS Medical Director.

Region “B”: represents skills and roles in which an individual has been educated

and certified, but are not part of the State license and credentialing. For example, a

Paramedic that trained as a corpsman is educated and certified in basic suturing,

however, the skill is not considered “core” in the civilian sector. It would now be

out of his/her scope of practice, and cannot be performed without special review

and authorization by the State and medical director.

Region “C”: represents skills and roles for which an individual is educated,

certified, and licensed, but has no local/jurisdictional credentialing. For example, an

off duty Paramedic arriving at the scene of an incident outside of his jurisdiction

usually is not credentialed to perform advanced skills. In this case, performing an

advanced skill would represent a violation of his scope of practice.

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II. Understanding Professional Scope Of Practice 18

Region “D”: represents skills or roles the State has authorized (licensed) but are not

addressed by initial education programs or certification processes. These skills

require local entities to assure the education and competency verification, in

addition to local credentialing. For example, rapid sequence induction for intubation

(RSI) in some States is legally permitted, but usually not taught as part of the initial

education, nor is it part of the certification process. Some individuals (for example,

flight paramedics) may be authorized to perform RSI; however, this is only

permissible if the local entity assumes the responsibility for satisfying the

requirements of education and certification of competency. Credentialing remains

mandatory, and additional process may be needed to satisfy local physician medical

direction that skills in this region are safe and appropriate. Nonetheless, all four

domains must be accomplished before any skill or role can be authorized.

Region “E”: represents skills or roles which a medical director wants an individual

to perform but for which they have not yet been educated, certified, or licensed to

perform. Typically, skills and roles in this region are new or emerging interventions

that have the potential to drive the future of EMS practice based on evolving

evidence. Innovations such as waveform capnography, CPAP, and the use of

naloxone by EMRs have all originated in this region. There is considerable State-to-

State variability in dealing with this situation. Some States have regulations that

restrict licensed individuals from functioning beyond their scope of practice. In

others, regulatory mechanisms exist that enable a local physician to assume

responsibility for the performance of new skills and roles performed by an EMS

provider. Most States fall somewhere between these extremes and have mechanisms

by which local medical directors can obtain an expansion/variance of a scope of

practice if they can demonstrate the need and appropriate mechanism to reasonably

assure patient safety. In these circumstances, if no process exists to obtain State

level authorization for additional skills or roles, then items that fall in Region “E”

cannot be practiced. Therefore it is important that States recognize the need for

innovation and progression within the field, and establish processes for Region E

interventions to be performed; appropriate education, evaluation and certification

under the medical director’s oversight must occur prior to implementation. Only

then can these new interventions work their way into the standardized education,

certification, and licensing domains to become part of the ever-evolving standard of

care.

In many States, day-to-day clarification of scopes of practice, management of an appeal process,

or otherwise assuring the adequacy of medical direction is the role of the State EMS Medical

Director. Some States have licensure boards, often consisting of medical directors,

administrators, peers, and public representatives that help adjudicate and clarify scope of practice

issues.

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II. Understanding Professional Scope Of Practice 19

Scope of Practice versus Standard of Care

Scope of practice does not define a standard of care, nor does it define what should be done in a

given situation (i.e., it is not a practice guideline or protocol). It defines what is legally permitted

to be done by some or all of the licensed individuals at that level, not what must be done. Table 1

describes some of the differences between scope of practice and standard of care.

Table 1: Relationship between scope of practice and standard of care

Scope of Practice Standard of Care

Purpose Deals with the question, “Are

you/were you allowed to do it?”

Deals with the question, “Did

you do the right thing and did

you do it properly?”

Legal implications Act of commission is a criminal

offense

Acts of commission or omission

not in conformance with the

standard of care may lead to civil

liability

Variability May vary from individual to

individual. Does not vary based

on circumstances.

Situational, depends on many

variables

Defined by Established by statute, rules,

regulations, precedent, and/or

licensure board interpretations

Determined by scope of practice,

literature, expert witnesses, and

juries

Miscellaneous It is difficult to regulate

knowledge through scope of

practice.

Used to evaluate the totality of

circumstances. What would a

reasonable EMS person do in the

same or similar circumstances?

A Comprehensive Approach to Safe and Effective Out of Hospital

Care

Scope of practice is only one part of health care regulation and regulation is only one component

of a comprehensive approach to improved patient care and safety. The primary goal of State

regulation of EMS personnel is to protect the public from harm by ensuring EMS personnel

possess a minimum level of competency and professional behaviors. Safe and effective EMS

care is the cumulative effect of a cascade of many individual decisions involving every level of

EMS leadership, medical direction, supervision, management, and regulation. Safe and effective

patient care is the first priority and shared responsibility of everyone within an EMS agency and

the EMS system. Safe and effective care cannot be accomplished through any single activity, but

is best accomplished with an integrated system of checks and balances. All components of this

comprehensive approach to safe and effective patient care are mutually supportive of and

dependent upon each other.

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III. Special Considerations 20

III. Special Considerations

Liability in EMS Licensing and Oversight

A license is the official or legal permission to engage in or perform a regulated activity. In the

United States, State governments generally hold the authority to issue licenses including EMS

licenses. This is important because States ultimately need to be in a position to halt EMS

personnel from performing in ways that are dangerous or harmful to the public.

Licensing differs from certification in that certification is an affirmation of competence while

licensing is the authorization to perform the regulated health care activity. EMS personnel most

commonly function on behalf of some volunteer or career organization that acts in a supervisory

relationship as the person’s employer.

EMS personnel have functioned under the supervision of physician medical directors since the

1960s. This physician oversight has been invaluable in assuring and improving the quality of

care provided by EMS personnel. The close relationship of EMS personnel and physicians in

this evolving health care discipline and descriptions of medical direction in early EMS curricula

has led to the impression and belief by some that medical direction physicians are extending their

licenses to authorize EMS practice. The logic of that belief would be that if an EMS person

acted incompetently or dangerously, the State would take an action on the physician medical

director’s license. Not only would that be ineffective in halting the EMS practitioner’s practice,

it would put at risk the physician who might be in a position to help correct whatever problem

exists with the EMS practitioner’s practice.

The concept that EMS personnel are somehow practicing “under the physician’s license” is

simply not accurate. The umbrella of physician supervision and collaboration can never be used

to replace the certification, scope of practice and individual responsibility of licensed EMS

personnel. EMS personnel hold their own license and the relevant State authority can restrict or

remove that license to stop incompetent or dangerous practice.

EMS personnel do however, practice under the oversight of physician medical directors. Medical

directors are expected to provide appropriate supervision in the interest of public safety and are

obligated to revoke or restrict local credentialing as appropriate. Failure to provide appropriate

oversight can be determined to be inadequate supervision and expose the physician to

professional liability. In this respect, physician medical directors can be accountable, not for

individual acts of EMS personnel, but for their larger oversight role.

Scope of Practice for Special Populations

EMS personnel are expected to meet the urgent health care needs of all patients with

consideration to age, race, gender, cultural, religious, and ethnic considerations consistent with

their defined scope of practice. Recognized special populations include, but may not be limited

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III. Special Considerations 21

to, children, older patients, lesbian, gay, bisexual, transgender, and questioning (LGBTQ)

patients, bariatric patients, patients with disabilities, and patients with limited access to health

care due to geographic, demographic, socioeconomic, or other reasons.

Scope of Practice During Disasters, Public Health Emergencies, and

Extraordinary Circumstances

The Practice Model is intended to cover a range of situations and circumstances where EMS

personnel may provide emergency care. It is virtually impossible to create a scope of practice

that takes into account every unique situation, extraordinary circumstance, and possible practice

situation. In some cases, EMS personnel may be the only medically trained individuals at the

scene of a disaster when other health care resources are overwhelmed. This document cannot

account for every situation, but rather is designed to establish a system that works for entry-level

personnel under normal circumstances. States may wish to modify or expand the scope of

practice of EMS personnel in times of disaster or crisis with proper education, medical oversight,

and quality assurance to reasonably protect patient safety.

Scope of Practice for EMS Personnel Functioning in Nontraditional

Roles

The delivery of health care has been transformed over the last half-century by exponential and

significant advances in medicine, research, and technology. The increasing portability and

affordability of diagnostic and treatment equipment and the demand to increase care quality

while reducing the cost of providing it has changed the demand for health care services in ways

that were not envisioned with the passage of the National Highway Safety Act in 196615. EMS

personnel are identifying volunteer and career opportunities in a range of nontraditional settings

that fulfill an important public health, public safety, and patient care need, such as large-scale

concerts, sporting events and festivals, industrial, frontier and wilderness environments, wildland

fire settings, community health, and more. Enabled by progressive rulemaking, occupational

partners and innovative health care systems have been successfully utilizing educated,

experienced, and licensed EMS personnel in patient care settings, such as health clinics and

hospitals for the past several years and they have become recognized as an invaluable member of

the health care team. States with practice restrictions based on location, vehicle use, agency type,

or transport provisions are encouraged to review existing laws, regulations, and policies to

identify barriers that prevent EMS personnel from functioning in any setting at a level to the full

extent of their education, certification, licensure, and credentialing.

Specialty Care Delivered by Licensed EMS Personnel

Specialization of EMS personnel continues to be an evolving area of interest to the national EMS

community. This reflects a broader specialization trend that has occurred in medicine for over a

century as well ongoing specialization in nursing and other allied health fields. In general,

specialization occurs in response to an identified need for an expanded body of knowledge and

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III. Special Considerations 22

skills that are best served by a formal supplemental educational and credentialing process. In

many instances throughout health care the development and oversight of a specialty recognition

process is lead by health professionals through specialty boards and implemented in conjunction

with State regulators. This approach effectively combines national consistency achieved through

the specialty certification process with the legal authority to practice.

Specialty recognition, credentialing, or endorsement is the outcome of a formally defined process

and mechanism for actively assessing that an individual possesses and has mastered a unique

body of knowledge over and above entry-level cognitive, affective, and psychomotor domains of

learning and that they can apply this knowledge and related skill set to improve care provided for

patients. Numerous health care and non-health care professions regulated by States have one or

more specialty certification areas that have been defined, in part, by members of the profession

itself. Several EMS specialties have emerged since the 2000 release of the Education Agenda.

Integration of specialty care requires appropriate educational preparation, a rigorous certification

process, integration with State scope of practice and licensure regulations, and local credentialing

by the medical director and EMS agency.

The legal authority for personnel to practice is established by State legislative action. Licensure

authority prohibits anyone from practicing a profession unless they are licensed and authorized

by the State, regardless of whether or not the individual has been certified by a nongovernmental

or private organization.

States often approach specialization policy though two mechanisms. The first is development of

an additional licensure level beyond those described in this model. The second is to enact scope

of practice regulations at the State level that allow for additional practice, often called an

endorsement, in addition to an existing license level. This second approach is used extensively in

the medical and nursing professions. Both approaches benefit from ongoing cooperation and

coordination with non-governmental specialty boards.

Military to Civilian EMS Transition

Military medics and corpsmen treat combat wounds in some of the harshest conditions that the

majority of civilian EMS personnel will likely never see and they are undoubtedly well qualified

to serve a domestic mission to achieve zero preventable deaths in the war on trauma

(#ZPD2025). While support for military to civilian EMS transition is broad, the cognitive,

affective, and psychomotor coursework for military medical trainees is variable depending on the

individual service member’s military assignment, which makes determining related equivalency

and awarding experiential credit for military service across five armed services branches

somewhat complex. Much work has been done to identify pathways for military corpsmen to

transition to civilian EMS positions:

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III. Special Considerations 23

• The U.S. Department of Defense has consolidated a vast majority of health care specialist

training across the armed services branches to the operational center at the Medical

Education and Training Campus (METC) at Fort Sam Houston, TX. METC is working

to ensure that more service-required education and training programs satisfy the ever-

increasing course completion requirements of the civilian sector.

• EMS programs are increasingly providing “advanced placement” evaluation and

assistance to separating service members, particularly at the AEMT and paramedic levels.

• Over the next several years, health science training programs at METC will transition to

the METC Branch Campus of the College of Allied Health Sciences at the Uniformed

Services University so that all military students will receive a consistent and recognizable

transcript from a regionally accredited degree granting institution of higher education.16

• States have developed an updated model for conducting EMS personnel licensure

evaluations including the integration of EMS licensees from other States and from the

military setting.

Course completion of a program that meets or exceeds the Education Standards signifies that an

individual has fulfilled entry-level education requirements that lead to National EMS

Certification provided by the National Registry of Emergency Medical Technicians (NREMT).

Active NREMT Certification has been demonstrated to be the most expeditious path for military

personnel to seek EMS licensure with the States.

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IV. Description of Levels 24

IV. Description of Levels

Emergency Medical Responder (EMR)

Description

The EMR is an out of hospital practitioner whose primary focus is to initiate immediate

lifesaving care to patients while ensuring patient access to the emergency medical services

system. EMRs possess the basic knowledge and skills necessary to provide lifesaving

interventions while awaiting additional EMS response and rely on an EMS or public safety

agency or larger scene response that includes other higher-level medical personnel. When

practicing in less populated areas, EMRs may have a low call volume coupled with being the

only care personnel for prolonged periods awaiting arrival of higher levels of care. EMRs may

assist, but should not be the highest-level person caring for a patient during ambulance transport.

EMRs are often the first to arrive on scene. They must quickly assess patient needs, initiate

treatment, and request additional resources.

Emergency Medical Responders:

• Function as part of a comprehensive EMS response, community, health, or public

safety system with clinical protocols and medical oversight.

• Perform basic interventions with minimal equipment to manage life threats, medical,

and psychological needs with minimal resources until other personnel can arrive.

• Are an important link within the 9-1-1 and emergency medical services systems.

Other Attributes

The focused and limited scope of this level makes it suitable for employee cross training in

settings where emergency medical care is not the EMRs primary job function. Examples include

firefighters, law enforcement, lifeguards, backcountry guides, community responders, industrial

workers and similar jobs. EMRs advocate health and safety practices that may help reduce harm

to the public.

Education Requirements

Successful completion of an EMR training program that is:

• Compliant with a uniform national standard for quality, and

• Approved by the State or US territory

Primary Role

Initiate patient care within the emergency medical services system.

Type of Education

Vocational/Technical setting

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IV. Description of Levels 25

• Certificate awarded for successful completion

Critical Thinking

Within a limited set of protocol-driven, clearly defined principles.

Level of Supervision

General medical oversight required. Assist higher-level personnel at the scene and during

transport.

Emergency Medical Technician (EMT)

Description

An EMT is a health professional whose primary focus is to respond to, assess and triage

emergent, urgent, and non-urgent requests for medical care, apply basic knowledge and skills

necessary to provide patient care and medical transportation to/from an emergency or health care

facility. Depending on a patient’s needs and/or system resources, EMTs are sometimes the

highest level of care a patient will receive during an ambulance transport. EMTs often are paired

with higher levels of personnel as part of an ambulance crew or other responding group. With

proper supervision, EMTs may serve as a patient care team member in a hospital or health care

setting to the full extent of their education, certification, licensure, and credentialing. In a

community setting, an EMT might visit patients at home and make observations that are reported

to a higher-level authority to help manage a patient’s care. When practicing in less populated

areas, EMTs may have low call volume coupled with being the only care personnel during

prolonged transports. EMTs may provide minimal supervision of lower level personnel. EMTs

can be the first to arrive on scene; they are expected to quickly assess patient conditions, provide

stabilizing measures, and request additional resources, as needed.

Emergency Medical Technicians:

• Function as part of a comprehensive EMS response, community, health, or public

safety system with defined clinical protocols and medical oversight.

• Perform interventions with the basic equipment typically found on an ambulance17 to

manage life threats, medical, and psychological needs.

• Are an important link within the continuum of the emergency care system from an out

of hospital response through the delivery of patients to definitive care.

Other Attributes

The majority of personnel in the EMS system are licensed at the EMT level. The EMT plays

many important roles and possesses the knowledge and skill set to initially manage any

emergency until a higher level of care can be accessed. In areas where AEMT or Paramedic

response is not available, the EMT may be the highest level of EMS personnel a patient

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IV. Description of Levels 26

encounters before reaching a hospital. EMTs advocate health and safety practices that may help

reduce harm to the public.

Education Requirements

Successful completion of an EMT training program that is:

• Compliant with a uniform national standard for quality, and

• Approved by the State or US territory

Primary Role

Provide basic patient care and medical transportation within the emergency care system.

Type of Education

Vocational/Technical setting

• Diploma or certificate awarded for successful completion.

Critical Thinking

Within a limited set of protocol-driven, clearly defined principles that:

o Engages in basic risk versus benefit analysis.

o Participates in making decisions about patient care, transport destinations, the need

for additional patient care resources, and similar judgments.

Level of Supervision

General medical oversight required. Some autonomy at basic life support level, assist higher-

level personnel at the scene and during patient transport.

Advanced Emergency Medical Technician (AEMT)

Description

The AEMT is a health professional whose primary focus is to respond to, assess and triage non-

urgent, urgent, and emergent requests for medical care, apply basic and focused advanced

knowledge and skills necessary to provide patient care and/or medical transportation, and

facilitate access to a higher level of care when the needs of the patient exceed the capability level

of the AEMT. The additional preparation beyond EMT prepares an AEMT to improve patient

care in common emergency conditions for which reasonably safe, targeted, and evidence-based

interventions exist. Interventions within the AEMT scope of practice may carry more risk if not

performed properly than interventions authorized for the EMR/EMT levels. With proper

supervision, AEMTs may serve as a patient care team member in a hospital or health care setting

to the full extent of their education, certification, licensure, and credentialing. In a community

setting an AEMT might visit patients at home and make observations that are reported to a

higher-level authority to help manage a patient’s care.

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IV. Description of Levels 27

Advanced Emergency Medical Technicians:

• Function as part of a comprehensive EMS response, community, health, or public

safety system with medical oversight.

• Perform interventions with the basic and advanced equipment typically found on an

ambulance.

• Perform focused advanced skills and pharmacological interventions that are engineered

to mitigate specific life-threatening conditions, medical, and psychological conditions

with a targeted set of skills beyond the level of an EMT.

• Function as an important link from the scene into the health care system.

Other Attributes

The learning objectives and additional clinical preparation for AEMTs exceed the level of an

EMT. In areas where Paramedic response is not available, the AEMT may be the highest level

of EMS personnel a patient encounters before reaching a hospital. AEMTs advocate health and

safety practices that may help reduce harm to the public.

Education Requirements

Successful completion of a nationally accredited or CAAHEP accredited AEMT program that

meets all other State/territorial requirements. (The target for full implementation of AEMT

program accreditation is January 1, 2025.)

Primary Role

Provide basic and focused advanced patient care; determine transportation needs within the

health care system.

Type of Education

Vocational/Technical or Academic setting

• Diploma, certificate, or associates degree awarded for successful completion.

Critical Thinking

Within a limited set of protocol-driven, clearly defined principles that:

o Engages in basic risk versus benefit analysis.

o Participates in making decisions about patient care, transport destinations, the need

for additional patient care resources, and similar judgments.

Level of Supervision

Medical oversight required. Minimal autonomy for limited advanced skills. Provides some

supervision of lower level personnel. Assist higher-level personnel at the scene and during

transport.

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IV. Description of Levels 28

Paramedic

Description

The paramedic is a health professional whose primary focus is to respond to, assess, and triage

emergent, urgent, and non-urgent requests for medical care, apply basic and advanced

knowledge and skills necessary to determine patient physiologic, psychological, and

psychosocial needs, administer medications, interpret and use diagnostic findings to implement

treatment, provide complex patient care, and facilitate referrals and/or access to a higher level of

care when the needs of the patient exceeds the capability level of the paramedic. Paramedics

often serve as a patient care team member in a hospital or other health care setting to the full

extent of their education, certification, licensure, and credentialing. Paramedics may work in

community settings where they take on additional responsibilities monitoring and evaluating the

needs of at-risk patients, as well as intervening to mitigate conditions that could lead to poor

outcomes. Paramedics help educate patients and the public in the prevention and/or management

of medical, health, psychological, and safety issues.

Paramedics:

• Function as part of a comprehensive EMS response, community, health, or public

safety system with advanced clinical protocols and medical oversight.

• Perform interventions with the basic and advanced equipment typically found on an

ambulance, including diagnostic equipment approved by an agency medical director.

• May provide specialized interfacility care during transport.

• Are an important link in the continuum of health care.

Other Attributes

Paramedics commonly facilitate medical decisions at an emergency scene and during transport.

Paramedics work in a variety of specialty care settings including but not limited to ground and

air ambulances, occupational, in hospital, and community settings. Academic preparation enables

paramedics to use a wide range of pharmacology, airway, and monitoring devices as well as to

utilize critical thinking skills to make complex judgments such as the need for transport from a

field site, alternate destination decisions, the level of personnel appropriate for transporting a

patient, and similar judgments. Due to the complexity of the Paramedic scope of practice and the

required integration of knowledge and skills, many training programs are moving towards

advanced training at the Associate degree or higher level.

Education Requirements

Successful completion of a nationally accredited Paramedic program that meets all other State

requirements.

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IV. Description of Levels 29

Primary Role

Provide advanced care in a variety of settings; interpretive and diagnostic capabilities; determine

destination needs within the health care system; specialty transport.

Type of Education

Academic setting

• Diploma, Certificate, Associate, or Bachelors/Baccalaureate Degree awarded for

successful completion.

Critical Thinking

Within a set of protocol-driven, clearly defined principles that:

o Engages in complex risk versus benefit analysis.

o Participates in making decisions about patient care, transport destinations, the need

for additional patient care resources, and similar judgments.

Level of Supervision

Paramedics operate with collaborative and accessible medical oversight, recognizing the need for

autonomous decision-making. Frequently provides supervision and coordination of lower level

personnel.

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V. Depth and Breadth of Knowledge 30

V. Depth and Breadth of Knowledge

“Breadth of learning refers to the full span of knowledge of a

subject. Depth of learning refers to the extent to which specific topics

are focused upon, amplified and explored. Within any area of study,

there will be both breadth and depth of learning, which increase as

students advance their knowledge.18”

It is important to note that the Practice Model and Education Standards assume a progression of

the three domains of learning (cognitive, affective, and psychomotor) that affects EMS practice

from the EMR level through the Paramedic level. That is, licensed personnel at each level are

responsible for all knowledge, judgments, and skills at their level and all levels preceding their

level. The Practice Model also assumes that EMS personnel not only receive requisite

knowledge, but they can comprehend data, apply knowledge, analyze and synthesize

information, and evaluate the outcomes of their actions.

Typically, scope of practice refers to the tasks and roles that licensed personnel are legally

authorized to perform. In general, it does not describe the requisite knowledge necessary to

perform those tasks and roles competently. As outlined in the Education Agenda, the

responsibility for determining the knowledge necessary to safely perform skills, tasks, and roles

falls to the EMS educators.

The increasing depth and breadth of cognitive, affective, and psychomotor material envisioned

across each level of EMS licensure is graphically represented in Figure 3.

Figure 3: Increasing Depth and Breadth of Knowledge from EMR through Paramedic

.

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V. Depth and Breadth of Knowledge 31

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VI. Interpretive Guidelines 32

VI. Interpretive Guidelines

The interpretive guidelines are used to help guide the users of this document by providing

additional insight into the discussions and deliberations that revolved around the decisions of the

Expert Panel. These interpretive guidelines represent the collective opinions of the Expert Panel

in June 2018.

The interpretive guidelines are included to allow future users to apply similar methodology in

deciding appropriateness of new interventions at each personnel level. They are illustrative and

NOT all-inclusive.

I. Skill – Airway/Ventilation/Oxygenation

I. Skill – Airway / Ventilation / Oxygenation

EMR EMT AEMT Paramedic

Airway – nasal X X X

Airway – oral X X X X

Airway – supraglottic X X

Bag-valve-mask (BVM) X X X X

CPAP X X X

Chest decompression - needle X

Chest tube placement – assist only X

Chest tube – monitoring and management X

Cricothyrotomy X

End tidal CO2 monitoring and

interpretation of waveform capnography X X

Gastric decompression – NG Tube X

Gastric decompression – OG Tube X

Head tilt - chin lift X X X X

Endotracheal intubation X

Jaw-thrust X X X X

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VI. Interpretive Guidelines 33

I. Skill – Airway / Ventilation / Oxygenation

EMR EMT AEMT Paramedic

Mouth-to-barrier X X X X

Mouth-to-mask X X X X

Mouth-to-mouth X X X X

Mouth-to-nose X X X X

Mouth-to-stoma X X X X

Airway Obstruction – dislodgement by

direct laryngoscopy X

Airway Obstruction – manual

dislodgement techniques X X X X

Oxygen therapy – High flow nasal

cannula X

Oxygen therapy – Humidifiers X X X

Oxygen therapy – Nasal cannula X X X X

Oxygen therapy – Non-rebreather mask X X X X

Oxygen therapy – partial rebreather mask X X X

Oxygen therapy – simple face mask X X X

Oxygen therapy – Venturi mask X X X

Pulse oximetry X X X

Suctioning – Upper airway X X X X

Suctioning – tracheobronchial of an

intubated patient X X

II. Skill – Cardiovascular/Circulation

II. Skill – Cardiovascular / Circulation

EMR EMT AEMT Paramedic

Cardiopulmonary resuscitation (CPR) X X X X

Cardiac monitoring – 12 lead ECG

acquisition and transmission X X X

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VI. Interpretive Guidelines 34

II. Skill – Cardiovascular / Circulation

EMR EMT AEMT Paramedic

Cardiac monitoring – 12 lead

electrocardiogram (interpretive) X

Cardioversion – electrical X

Defibrillation – automated / semi-

automated X X X X

Defibrillation – manual X

Hemorrhage control – direct pressure X X X X

Hemorrhage control – tourniquet X X X X

Hemorrhage control – wound packing X X X X

Transvenous cardiac pacing – monitoring

and maintenance X

Mechanical CPR device X X X

Telemetric monitoring devices and

transmission of clinical data, including

video data X X X

Transcutaneous pacing X

III. Skill – Splinting, Spinal Motion Restriction (SMR), and Patient

Restraint

III. Skill – Splinting, Spinal Motion Restriction (SMR), and Patient Restraint

EMR EMT AEMT Paramedic

Cervical collar X X X X

Long spine board X X X

Manual cervical stabilization X X X X

Seated SMR (KED, etc) X X X

Extremity stabilization - manual X X X X

Extremity splinting X X X X

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VI. Interpretive Guidelines 35

III. Skill – Splinting, Spinal Motion Restriction (SMR), and Patient Restraint

EMR EMT AEMT Paramedic

Splint – traction X X X

Mechanical patient restraint X X X

Emergency moves for endangered

patients X X X X

IV. Skill – Medication Administration – Routes

IV. Skill – Medication Administration – Routes

EMR EMT AEMT Paramedic

Aerosolized/nebulized X X X

Endotracheal tube X

Inhaled X X X

Intradermal X

Intramuscular X X

Intramuscular – auto-injector X X X X

Intranasal X X

Intranasal - unit-dosed, premeasured X X X X

Intraosseous X X

Intravenous X X

Mucosal/Sublingual X X X

Nasogastric X

Oral X X X

Rectal X

Subcutaneous X

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VI. Interpretive Guidelines 36

IV. Skill – Medication Administration – Routes

EMR EMT AEMT Paramedic

Topical X

Transdermal X

V. Medical Director Approved Medications

V. Medical Director Approved Medications

EMR EMT AEMT Paramedic

Use of epinephrine (auto-injector) for

anaphylaxis (supplied and carried by the

EMS agency) X X X

Use of auto-injector antidotes for

chemical/hazardous material exposures X X X X

Use of opioid antagonist auto-injector for

suspected opioid overdose X X X X

Immunizations X X

Inhaled – beta agonist/bronchodilator and

anticholinergic for dyspnea and wheezing X X X

Inhaled – monitor patient administered

(i.e. nitrous oxide) X X

Intranasal - opioid antagonist for

suspected opioid overdose X X X X

Intravenous X1 X

Maintain an infusion of blood or blood

products X

Oral aspirin for chest pain of suspected

ischemic origin X X X

Oral glucose for suspected hypoglycemia X X X

Oral over the counter (OTC) analgesics

for pain or fever X X X

OTC medications, oral and topical X

Parenteral analgesia for pain X X

1 Limited to analgesia, antinausea/antiemetic, dextrose, epinephrine, glucagon, naloxone, and others defined by state/local

protocol.

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VI. Interpretive Guidelines 37

V. Medical Director Approved Medications

EMR EMT AEMT Paramedic

Sublingual nitroglycerin for chest pain of

suspected ischemic origin – limited to

patient’s own prescribed medication X

Sublingual nitroglycerin for chest pain of

suspected ischemic origin X X

Thrombolytics X

VI. Skill – IV Initiation/Maintenance Fluids

VI. Skill – IV Initiation/Maintenance Fluids

EMR EMT AEMT Paramedic

Access indwelling catheters and

implanted central IV ports X

Central line – monitoring X

Intraosseous – initiation, peds or adult X X

Intravenous access X X

Intravenous initiation - peripheral X X

Intravenous – maintenance of non-

medicated IV fluids X X

Intravenous – maintenance of medicated IV fluids

X

VII. Skill – Miscellaneous

VII. Skill – Miscellaneous EMR EMT AEMT Paramedic

Assisted delivery (childbirth) X X X X

Assisted complicated delivery

(childbirth) X X X

Blood chemistry analysis X

Blood pressure automated X X X

Blood pressure – manual X X X X

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VI. Interpretive Guidelines 38

VII. Skill – Miscellaneous EMR EMT AEMT Paramedic

Blood glucose monitoring X X X

Eye irrigation X X X X

Eye irrigation –hands free irrigation using

sterile eye irrigation device X

Patient transport X X X

Venous blood sampling X X

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VII. Definitions 39

VII. Definitions

Academic—Based on formal education; scholarly; conventional.

Academic institution—A body or establishment instituted for an educational purpose and

providing college credits or awarding degrees.

Accreditation—The granting of approval by an official review board after specific requirements

have been met. The review board is non-governmental and the review is collegial and based on

self-assessment, peer assessment, and judgment. The purpose of accreditation is student

protection and public accountability.

Advanced level care—Care that has greater potential benefit to the patient, but also greater

potential risk to the patient if improperly or inappropriately performed, is more difficult to attain

and maintain competency in, and requires significant background knowledge in basic and

applied sciences. These include invasive and pharmacological interventions.

Administered medication—The act of giving a medication to a patient that has been stocked

and carried by EMS personnel. The patient may not have previously been determined by a

physician to be an appropriate recipient of the medication.

Certification—An external verification of the competencies that an individual has achieved that

typically involves an examination process.

Continuing education—The continual process of life-long learning.

Competence—The application of knowledge and the interpersonal, decision-making and

psychomotor skills expected for the practice role, within the context of public health, safety and

welfare.

Core content—The central elements of a professional field of study. The core content does not

specify the course of study.

Credentialing—A clinical determination that is the responsibility of a physician medical

director that authorizes a practitioner to perform a skill or role.

Curriculum—A particular course of study, often in a special field. For EMS education it has

traditionally included detailed lesson plans. (The responsibility for EMS curriculum has shifted

to EMS educators and EMS programs based on the Education Standards.)

Educational affiliation—An association with a learning institution (academic), the extent to

which can vary greatly from recognition to integration.

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VII. Definitions 40

Entry-level competence—The level of competence expected of an individual who is about to

begin a career. Entry-level competence is sometimes defined as the minimum competence

necessary to practice safely and effectively.

EMS system—Any specific arrangement of emergency medical personnel, equipment, and

supplies designed to function in a coordinated fashion. May be local, regional, State, or national.

Licensure—The legal authority granted to an individual by the State to perform certain

restricted activities. A license is generally considered a privilege and not a right.

National EMS Core Content—The document that defines the domain of out of hospital care.

National EMS Education Program Accreditation—The national accreditation process for

institutions that sponsor EMS educational programs identified by the Education Agenda.

Nationally recognized accrediting agency—An accrediting agency that the U.S. Secretary of

Education recognizes under Title 34 CFR Part 602—The Secretary’s Recognition of Accrediting

Agencies19.

National EMS Education Standards—The document that defines the terminal learning

objectives for each Nationally defined EMS licensure level.

National EMS Scope of Practice Model—The document that defines scope of practice for each

Nationally defined EMS licensure level.

Outcome—The short-, intermediate-, or long-term consequence or visible result of treatment,

particularly as it pertains to a patient's return to societal function.

Practice analysis—A study conducted to determine the frequency and criticality of the tasks

performed in practice.

Registration—A listing of individuals who have met the requirements of the registration

service.

Registration agency—Agency traditionally responsible for the delivery of a product used to

evaluate a chosen area. States may voluntarily adopt this product as part of their licensing

process. The registration agency is also responsible for gathering and housing data to support the

validity and reliability of their product.

Regulation—Either a rule or a statute that prescribes the management, governance, or operating

parameters for a given group; tends to be a function of administrative agencies to which a

legislative body has delegated authority to promulgate rules/regulations to "regulate a given

industry or profession." Most regulations are intended to protect the public health, safety, and

welfare.

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VII. Definitions 41

Scope of practice—Defined parameters of various duties or services that may be provided by an

individual with specific credentials. Whether regulated by rule, statute, or court decision, it

represents the limits of services an individual may legally perform.

Testing agency—Agency traditionally responsible for delivering a contracted examination. The

responsibility of interpreting the results and defending the validity of those judgments is placed

on the contractor.

Vocational/Technical—Refers to schools or programs specializing in the skilled trades, applied

sciences, technology, and career preparation.

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Appendix I. History of Occupational Regulation in EMS 42

Appendix I. History of Occupational Regulation in EMS

The development of modern civilian EMS stems largely from lessons learned in providing

medical care to soldiers injured in military conflict.

Building on these lessons, a number of rescue squads and ambulance services emerged in the

civilian sector, often community-based in nature. Hospitals and funeral homes were also

common sources of nascent response and transportation systems. While well intentioned, most of

these personnel were untrained, poorly equipped, unorganized, and unsophisticated. The systems

were unregulated, and no State or national standards existed. By the 1960s, prehospital care in

the United States had evolved into a patchwork of well intentioned but uncoordinated efforts.

This all changed in the mid-1960s.

In 1960, the President’s Committee for Traffic Safety recognized the need to address “Health,

Medical Care and Transportation of the Injured” to reduce the nation’s highway fatalities and

injuries.

In 1966, the National Academy of Sciences published a “white paper” report titled Accidental

Death and Disability: The Neglected Disease of Modern Society20. This report quantified the

magnitude of traffic-related death and disability while vividly describing the deficiencies in

prehospital care in the United States. The white paper made a number of recommendations

regarding ambulance systems, including a call for ambulance standards, State-level policies and

regulations, and adopting methodology for providing consistent ambulance services at the local

level (National Academy of Sciences National Research Council, 1966).

The Highway Safety Act of 1966 required each State to have a highway safety program that

complied with uniform Federal standards, including “emergency services.” This provided the

impetus for the National Highway Traffic Safety Administration’s early leadership role in EMS

system improvements. Initial NHTSA EMS efforts were focused on improving the education of

prehospital personnel such as the writing of the National Standard Curricula (NSC). Funding was

also provided to assist States with the development of State EMS Offices. Subsequent NHTSA

efforts were oriented toward comprehensive EMS system development and included, for

instance, model State EMS legislation (Weingroff and Seabron, circa 2003).

The genesis of State EMS systems can also be traced to the early 1970s, when an unprecedented

level of funding from the Federal Government and the Robert Wood Johnson Foundation

prompted the establishment of regional EMS systems and demonstration projects throughout the

country. The Emergency Medical Services Systems Act of 197321 (enacted by Congress as Title

XII of the Public Health Service Act), yielded eight years and over $300 million of investment in

EMS systems planning and implementation. The availability of EMS personnel and their training

were two components that eligible entities were required to focus on, resulting in the first

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Appendix I. History of Occupational Regulation in EMS 43

generation of legislation and regulation of EMS personnel levels (National Highway Traffic

Safety Administration, 1996).

In 1966, the National Academy of Sciences/National Research Council Committee on Trauma

published the landmark document; Accidental Death and Disability: The Neglected Disease of

Modern Society that called for improved training of ambulance personnel. Also in 1966, the

Federal Highway Safety Act required each State to have a highway safety program that complied

with uniform Federal standards, including “emergency services.” That requirement provided the

impetus for the National Highway Traffic Safety Administration’s (NHTSA) early leadership

role in EMS system improvements. Initial NHTSA EMS efforts were focused on improving the

education of prehospital personnel such as the writing of the National Standard Curricula (NSC).

Funding was also provided to assist States with the development of State EMS Offices.

Subsequent NHTSA efforts were oriented toward comprehensive EMS system development and

included, for instance, model State EMS legislation

Beginning in 1971 NHTSA published the first 81-hour curriculum for training EMT-Ambulance

personnel. Other NSC followed for EMT-Paramedics and EMT-Intermediates. These propelled

EMS systems forward in terms of standardizing the preparation of people filling roles in

providing prehospital emergency care. The NSC gave detailed “how to teach this course”

guidance down to the minute in how much time to spend on specific learning objectives. It was

initially helpful to instructors who had never taught anyone to care for patients in the prehospital

environment. The NSC became functionally synonymous with the scope of practice that EMS

personnel could perform. EMS textbooks were published to align with the NSC. Many States

referenced the NSC in their statutes and rules.

The practical effect of the NSC for EMS personnel was, an EMS person could generally do what

they were taught to do. The practice and educational preparation of most other allied health

professions begins with agreement on what a person in the job can do (i.e. a scope of practice)

and then developing the education resources to prepare a qualified person to do that role. For

EMS, education was driving practice and for all other professions, practice drives education.

As EMS systems began to mature, limitations of the NSC became increasingly evident. A few

examples of these limitations included:

• Integration of new technologies and evidence. When AEDs became available and

proved to be both reliable and effective for cardiac arrest resuscitation, there had to be an

update to the NSC before use of AEDs could be widely taught to EMS personnel. The

opposite was also true as EMS devices or practices began to be shown as harmful. The

only way to remove content from teaching and practice was to revise the NSC.

• The professionalism of EMS educators. EMS courses began to be taught in many areas

by experienced adult educators. These educators questioned the constraints of the NSC

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Appendix I. History of Occupational Regulation in EMS 44

when they found they needed more or less time than what was called for. The NSC

provided no flexibility for how to deliver EMS courses.

• State EMS Office role conflict. States have the responsibility of setting scopes of

practice for all levels of health care personnel and those who adopted the NSC

functionally handed off this responsibility to a national document. There was no

effective way structurally for States to reference the NSC and make local adaptations to

both teaching and practice.

As a practical matter, the NSC also proved difficult and expensive to update. Controversy on

periodic revisions stemmed from debate about EMS practice rather than updates to the education

program.

The development of the EMS Agenda for the Future and the follow on EMS Education Agenda

for the Future: A Systems Approach called for a new model of EMS education. Central to the

new model was a National EMS Scope of Practice Model (SoPM) setting a floor on expectations

for what every person would be prepared to do in their role. Once the SoPM was established,

National EMS Education Standards were developed to guide instructors in the depth and breadth

of content to be taught. The development of curricula on how best to teach the courses at each

level is now left to individual instructors. EMS publishers provide an array of texts and other

educational support materials.

One function of State EMS offices was to ensure the competence of the State’s EMS personnel.

States employed a number of strategies to help assure safe and effective EMS practice, including

licensure and certification. Unfortunately, these terms developed multiple connotations in EMS.

In some cases, the meanings differed from other disciplines, causing confusion and inconsistency

at the national level.

In 1981, the Omnibus Budget Reconciliation Act (OBRA) eliminated the categorical federal

funding to states established by the 1973 EMS Systems Act in favor of block grants to states for

preventive health and health services. This change shifted responsibility for EMS from the

federal to the state level22. By 1990, EMS in the United States had enjoyed many successes. Not

only did EMS systems grow, but EMS became a career and volunteer activity for hundreds of

thousands of talented, committed, and dedicated individuals. Emergency medical care was

available to virtually every citizen in the country by simply dialing 9-1-1 from any telephone.

Despite this progress, EMS was affected by a number of factors in the broader health care

system.

In 1992, the National Association of EMS Physicians (NAEMSP) and the National Association

of State EMS Directors (NASEMSD) saw a need for a long-term strategic direction for EMS,

and the EMS Agenda for the Future was initiated with support from the National Highway

Traffic Safety Administration and the Maternal and Child Health Bureau (MCHB) of the Heath

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Appendix I. History of Occupational Regulation in EMS 45

Resources and Services Administration (HRSA). Published in 1996, the EMS Agenda for the

Future proposed a bold vision for greater integration of EMS into the U.S. health care system.

In 1993, the National Registry of EMTs (NREMT) released the National Emergency Medical

Services Education and Practice Blueprint. The Blueprint defined an EMS educational and

training system that would provide both the flexibility and structure needed to guide the

development of national standard training curricula and guide the issuance of licensure and

certification by the individual States.

In 1998, the Pew Health Professions Commission Taskforce on Health Care Workforce

Regulation published Strengthening Consumer Protection: Priorities for Health Care Workforce

Regulation (Finocchio, Dower et al., 1998)23. The report recommended that a national policy

advisory board develop standards, including model legislative language, for uniform scopes of

practice authority for the health professions. The report emphasized the need for States to enact

and implement scopes of practice that are nationally uniform and based on the standards and

models developed by the national policy advisory body.

Also in 1998, demonstrating their commitment to the EMS Agenda, NHTSA and HRSA jointly

supported a two-year project to develop an integrated system of EMS regulation, education,

certification, licensure, and educational program accreditation. The result was the EMS

Education Agenda for the Future: A Systems Approach, which recognized the need for a

systematic approach to meet the needs of the current EMS system while moving toward the

vision proposed in the 1996 EMS Agenda for the Future. The EMS Education Agenda called for

a more traditional approach to licensing EMS personnel.

A coordinated national EMS system continues to be in the best interest of States, EMS

personnel, and the public. State EMS offices, while working in cooperation with their

stakeholders, should implement scope of practice regulations that are as close as possible to

those described in the National EMS Scope of Practice Model. This will help with professional

recognition of EMS personnel, facilitate reciprocity, decrease confusion, and enable the

development of high quality support systems to benefit the entire system.

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Appendix II. Changes and Considerations from the 2007 Practice Model 46

Appendix II. Changes and Considerations from the 2007

Practice Model

The 2018 version of the Practice Model represents one frame of a motion picture of evolving

EMS practice. Research and technology are constantly evolving and will continue to drive

changes to EMS education and practice. Having the context for what did or did not change from

the 2007 Practice Model may be useful in understanding some of the content in this document.

The entire revision team deeply appreciates the thoughtful input received from the EMS

community during multiple public reviews. While not every comment or suggestion was

ultimately incorporated in the revision, all of them were considered and collectively played an

important role in shaping the 2018 National EMS Scope of Practice Model.

Much of the effort in updating the 2018 Practice Model was focused on describing the

interdependence between education, certification, licensure and credentialing and the narrative

descriptions of each level, while attempting to more clearly document expectations in a way to

minimize scope creep between the levels. While it is tempting to look at the specific list of skills

included in the Interpretive Guidelines section, that list cannot be used to provide a complete

understanding of the 2018 Practice Model for any level. The Interpretive Guidelines included in

this document are intended to illustrate the kinds of skills and interventions personnel at various

levels are educated, certified, licensed and otherwise qualified to do. This does not mean that

every person at a particular level will routinely do every skill on the Interpretive Guideline list.

One example of this is the obtaining and transmitting 12 lead electrocardiograms (ECG) at the

EMT level. The Expert Panel recognized the strong research evidence to support the value of

this skill for improving patient outcomes, especially in rural settings, however some systems

have readily available paramedics and EMT’s might not be utilized to provide this technology in

such systems. The Expert Panel also recognized that the cost of technology might be prohibitive

for some EMT level agencies. Accordingly, this is one example of a skill on which EMTs (and

other levels of EMS personnel) will routinely be educated and tested but that preparation does

not imply that the technology must or even should be available in every practice setting where

EMTs function. In other words, such a task should be valued/permitted but not required if the

necessary equipment/resources to complete the task are not available to personnel.

Finally, States maintain the regulatory flexibility to permit licensees to exceed the Practice

Model but they do so along with the need to develop learning objectives, educational content,

competency measures, and a credentialing process to ensure safe practice. As an example, some

States allow licensed EMTs to draw up a unit dose of epinephrine for IM injection to treat

anaphylaxis from a single or multi-dose vial although this activity is dependent on strict

oversight by a physician medical director and is not permitted in all jurisdictions.

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Appendix II. Changes and Considerations from the 2007 Practice Model 47

Nomenclature

The Expert Panel considered a recommendation24 from the National EMS Advisory Council

(NEMSAC) to recognize and use the term “paramedicine” to describe the professional discipline

that is currently recognized as EMS. Because the national discussion on this important topic has

just begun, the group ultimately did not support a change to nomenclature for the 2018 Practice

Model revision. When greater consensus among national EMS organizations and other EMS

stakeholders is achieved, the recommendation could be considered during the next revision

cycle.

Academic Degree Requirements for Paramedics

Consideration was given by the Expert Panel to calling for an associate degree as an entry-level

education requirement for paramedics. Arguments in favor of this change include recognition of

the complexity and sometimes ambiguity inherent to paramedic practice, increasing the

professional recognition of paramedics, a logical pathway towards better compensation, and

comparability with other health care professions. Arguments against this change include the

challenges of integrating associate degree academic preparation into fire, hospital or other non-

academic institution based programs. Concerns were voiced that increasing academic

preparation requirements could increase the cost of education, shrink the hiring pool of

paramedics for employers and threaten existing paramedic level service delivery programs. The

Expert Panel considers this topic as a subject worthy of further national debate and exploration.

While the group clearly recognizes education as the foundation of any profession’s scope of

practice, the difficulty of considering transitional variables such as grandfathering existing

personnel and programs, workforce recruitment and retention, etc. were beyond the scope of this

project.

Attendant Qualifications for Ambulance Transport The Expert Panel was asked to evaluate the practice of EMRs serving as part of an ambulance

crew, and more specifically as the primary care giver during ambulance transport; meaning an

EMR attending to the patient in the back of an ambulance enroute to a medical facility without a

higher level of licensed EMS practitioner physically present in the same compartment as the

patient.

While defining ambulance crew composition is outside the scope of this document, the Expert

Panel did consider the lack of scientific evidence to support the utilization of EMRs as a means

to fulfill clinical staffing requirements during the transport phase of EMS care when it developed

the description for an EMR in Section IV of this document. Considering the education,

certification, licensing, and credentialing processes pertaining to EMS practice, the Expert Panel

reaffirms that while an EMR may be used to assist patient care in an ambulance, an EMT (or

higher level personnel) must be physically present in the patient compartment and assume

responsibility for the delivery of care during transport.

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Appendix II. Changes and Considerations from the 2007 Practice Model 48

Patients transported by ambulance require ongoing assessment and treatment that is intended to

ensure their continued safety and positive clinical outcomes. Patient condition during transport

can decompensate quickly, requiring a greater depth and breadth of knowledge that enables EMS

personnel to anticipate and interpret subtle physiologic changes and provide interventions that

are not taught at the EMR level.

States are encouraged to help communities identify resources to ensure licensed practitioners at

the EMT or higher levels are available to care for patients that require transport by an

ambulance.

Portable Technologies

Exponential improvements and availability of portable technologies, such as left ventricular

assist devices (LVAD), patient controlled analgesia pumps, transport ventilators, etc., creates

complex challenges for education and credentialing that did not exist a decade ago. Such patient

care needs may be encountered by all levels of personnel in community and 9-1-1 settings and

also with patients originating in health care facilities during transfers. Even when the patient’s

condition would not require EMS interaction with a device or intervention during transport, the

variability of circumstances under which EMS delivery systems will likely encounter these

patients steered the Expert Panel away from a call for specific levels of EMS personnel to be

qualified in managing complex technologies, including non-invasive diagnostic equipment (e.g.,

ultrasound.) The actions of EMS personnel with regard to portable equipment and technologies

have intentionally been left to local medical director credentialing.

Deletions/Updates

Evolution and fine-tuning of the Interpretive Guidelines to eliminate redundancy resulted in

changes that may be perceived as certain skills being eliminated from the Practice Model. The

only “true” deletions include Military AntiShock Trousers (MAST)/Pneumatic AntiShock

Garment (PASG), spinal “immobilization” (this terminology has been revised), demand valves,

carotid massage, automated transport ventilators at the EMT level (deferred to a decision by the

medical director), and modified jaw thrust for trauma. Newer evidence suggests that these

references are antiquated and/or no longer recommended. Spinal immobilization was amended

to reflect current thinking on spinal motion restriction and additional skills were incorporated at

all levels. The topic of “assisting” patients with their own prescribed medications was also

revisited. The mechanical task of opening bottles or providing a drink of water aside, aid

associated with placing a tablet in the patient’s mouth, activating an inhaler, or delivering a dose

of medication via autoinjector is clearly an act of medication administration. Administration of

medication requires a thorough understanding of the drug, including how it moves through the

body, when it needs to be administered, possible side effects and dangerous reactions, proper

storage, handling, and disposal, and an entire process for confirming patient identification (for

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Appendix II. Changes and Considerations from the 2007 Practice Model 49

the prescription), route, dose, timing, expiration dates, and that the container actually contains

the medication the label says is intended. Medication errors happen all too often in the United

States, even when drugs are given by professionals. In fact, medication errors are the cause of 1.3

million injuries each year. These errors are due to the wrong drug, dose, timing, or route of

administration. Preparing, giving and evaluating the effectiveness of prescription and non-

prescription medication is not in the scope of practice for EMS personnel, with the exceptions

described in the Interpretive Guidelines and those authorized by the State and physician medical

director. References to “assist patients in taking their own prescribed medications” have been

identified as confusing by educators and practitioners and the Expert Panel has advised they be

removed from the Practice Model.

Other elements that were removed from the 2007 Interpretive Guidelines were intended to

minimize redundancy and not intended to reflect removal from the Practice Model. Examples

include cricoid pressure (considered to be a component of airway management) and therapeutic

PEEP (considered to be a component of ventilator management at the paramedic level).

Additions to the Interpretive Guidelines

The Expert Panel considered several proposed additions to the Interpretive Guidelines and an

NREMT Practice Analysis was utilized to evaluate the frequency and level of skills. Sensitive to

the impact of increased didactic and psychomotor instruction that effectively translates to added

course time and potential monetary expense to programs and student candidates, the Expert

Panel considered changes in practice by addressing the following questions:

1. Is there evidence that the procedure or skill is beneficial to public health?

2. What is the clinical evidence that the new skill or technique as used by EMS personnel will

promote access to quality health care or improve patient outcomes?

3. What is the appropriate level of education, certification, licensure and credentialing needed to

safely perform the task/skill?

Several of the suggestions received by the Expert Panel were felt to be above the level of entry-

level personnel and were not included. In particular, interventions that are regularly performed

by the lay public, such as self-administered medications, blood glucose monitoring, and pulse

oximetry were considered at length. It is noted that patients receive health education and training

from their primary care provider to perform activities that are tailored to their personal medical

histories and response to prescribed interventions over time. The Expert Panel maintains that

licensed individuals at all levels are highly accountable for the medical care they provide as well

as the maintenance and calibration of medical equipment used in the course of a patient

encounter. Health professionals are not only educated to provide an intervention, they receive

education in the associated risks and potential complications, related pharmacology (when

medications are involved), and they are able to analyze the effectiveness of treatment. Perhaps

the most critical difference between the lay public and EMS personnel assuming responsibility

for a particular task/skill: licensed individuals are taught to assimilate information and apply

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Appendix II. Changes and Considerations from the 2007 Practice Model 50

critical thinking skills to know when to and when not to apply an intervention in a particular

scenario. In the example of blood glucose monitoring, it is also important to note that the use of

such devices by EMS personnel invokes the federal-level Clinical Laboratory Improvement

Amendments25 (CLIA) to the Public Health Services Act. In regards to pulse oximeters (that can

be purchased inexpensively at discount stores), there is no evidence to support an assertion that a

pulse oximeter in the hands of an EMR (or other level of EMS practitioner) is more effective

than hands on patient assessment in determining the need for supplemental oxygen although

false readings from a variety of causes have resulted in undetected patient compromise and a

false sense of security by users. Such equipment are adjuncts that should be used judiciously in

conjunction with sound clinical judgment. Of the remaining tasks/skills, the Expert Panel

deliberated which level was most appropriate to implement the task/skill.

The Expert Panel concluded that spinal motion restriction using cervical collars and basic

splinting for suspected extremity fractures were appropriate additions to the Practice Model at

the EMR level.

At the EMT level, the Expert Panel agreed on the administration of beta agonists and

anticholinergics, oral over-the-counter (OTC) analgesics for pain or fever, blood glucose

monitoring, continuous positive airway pressure devices (CPAP), and pulse oximetry. The

Expert Panel also agrees that there will be instances of lower level personnel providing

assistance to higher levels — assisting with skills of the high-level personnel when the higher-

level personnel does the key portion of the procedure, the assistance is authorized by the medical

director, the assistance is in the direct presence and supervision of the higher-level personnel,

and the assistance is permitted by the State.

The use of supraglottic airways (SGA) and waveform capnography at the EMT level was

extensively debated. Several public commenters expressed a lack of support on draft language

that proposed to add them to the interpretive guidelines for EMTs during the national

engagement period. The Expert Panel was evenly divided on the topic. Several “pros” and

“cons” for adding SGA and waveform capnography for EMTs at the national level were

considered. It was noted that several jurisdictions are already using SGA as a more definitive

airway than the BVM although some panelists added that the BVM is not taught well or used

effectively in many cases. Major “cons” point to a critical patient safety concern if an SGA is not

placed properly or is not verified using waveform capnography. Many felt the education for SGA

and waveform capnography would add significant time and increase expense to the EMT

program, a consideration that was worrisome and expressed by the public and members of the

Expert Panel. Others suggested that BVM ventilation may not be done well, but a misplaced

advanced airway could lead to no ventilation and patient detriment or demise. Finally, a limited

review of the literature highlights the fact there is a general lack of evidence that SGA improves

outcomes in cardiac arrest or other etiologies over BVM ventilation. The Expert Panel concluded

that while SGA and waveform capnography could successfully be taught and measured at the

EMT level, it is an intervention that should be reserved for an experienced practitioner and

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Appendix II. Changes and Considerations from the 2007 Practice Model 51

therefore, is not a prudent addition as an entry-level skill to the Practice Model for an EMT at

this time. Some States currently allow licensed EMTs to use SGA and/or waveform

capnography although this activity is dependent on strict oversight by a physician medical

director and is not permitted in all jurisdictions.

Additions to the AEMT level include monitoring and interpretation of waveform capnography,

additional intravenous medications (such as epinephrine during cardiac arrest and ondansetron),

and parenteral analgesia for pain.

The Paramedic scope of practice was considered most in alignment with current practice,

however, the Expert Panel recommended the addition of high flow nasal cannula, and expanded

use of OTC medications.

None of these changes should be considered “in effect” until officially adopted by the State

licensing authority and medical director.

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Appendix III. Legal Differences Between Certification and Licensure 52

Appendix III. Legal Differences Between Certification and

Licensure

Used with permission: National Registry of Emergency Medical Technicians

https://www.nremt.org/rwd/public/document/certification_licensure

Although the general public continues to use the terms interchangeably, there are important

functional distinctions between certification and licensure.

Certification

The federal government has defined “certification” as the process by which a non-governmental

organization grants recognition to an individual who has met predetermined qualifications

specified by that organization.26 Similarly, the National Commission for Certifying Agencies

defines certification as “a process, often voluntary, by which individuals who have demonstrated

the level of knowledge and skill required in the profession, occupation, role, or skill are

identified to the public and other stakeholders.”27

Accordingly, there are three hallmarks of certification (as functionally defined). Certification is:

1. voluntary process;

2. by a private organization;

3. for the purpose of providing the public information on those individuals who have

successfully completed the certification process (usually entailing successful completion

of educational and testing requirements) and demonstrated their ability to perform their

profession competently.

Nearly every profession certifies its members in some way, but a prime example is medicine.

Private certifying boards certify physician specialists. Although certification may assist a

physician in obtaining hospital privileges, or participating as a preferred provider within a health

insurer’s network, it does not affect his legal authority to practice medicine. For instance, a

surgeon can practice medicine in any state in which he is licensed regardless of whether or not he

is certified by the American Board of Surgery.

Licensure

Licensure, on the other hand, is the state’s grant of legal authority, pursuant to the state’s police

powers, to practice a profession within a designated scope of practice. Under the licensure

system, states define, by statute, the tasks and function or scope of practice of a profession and

provide that these tasks may be legally performed only by those who are licensed. As such,

licensure prohibits anyone from practicing the profession who is not licensed, regardless of

whether or not the individual has been certified by a private organization.

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Appendix III. Legal Differences Between Certification and Licensure 53

What if my state certifies, not licenses, EMS professionals?

Confusion between the terms “certification” and “licensure” arises because many states call their

licensure processes “certification,” particularly when they incorporate the standards and

requirements of private certifying bodies in their licensing statutes and require that an individual

be certified in order to have state authorization to practice. The use of certification by the

NREMT by some states as a basis for granting individuals the right to practice as EMTs and

calling the authorization granted “certification” is an example of this practice. Nevertheless,

certification by the National Registry, by itself, does not give an individual the right to practice.

Regardless of what descriptive title is used by a state agency, if an occupation has a

statutorily or regulatorily defined scope of practice and only individuals authorized by the

state can perform those functions and activities, the authorized individuals are licensed. It

does not matter if the authorization is called something other than a license; the

authorization has the legal effect of a license.

In sum, the NREMT is a private certifying organization. The various State EMS Offices or like

agencies serve as the state licensing agencies. Certification by the NREMT is a distinct process

from licensure; and it serves the important independent purpose of identifying for the public,

state licensure agencies and employers, those individuals who have successfully completed the

Registry’s educational requirements and demonstrated their skills and abilities in the mandated

examinations. Furthermore, the NREMT’s tracking of adverse licensure actions and criminal

convictions provides an important source of information, which protects the public and aids in

the mobility of EMS providers.

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Appendix IV. Acknowledgements 54

Appendix IV. Acknowledgements

Subject Matter Expert Panel

Co-Chairmen

Scott Bourn PhD RN FACHE

Securisyn Medical & ESO Solutions

Parker, CO

Peter P. Taillac MD FACEP FAEMS

University of Utah School of Medicine

State EMS Medical Director, Utah Department of Health

Salt Lake City, UT

American Academy Of Pediatrics

Brian Moore MD FAAP

Associate Professor of Emergency Medicine, University of New Mexico

Albuquerque, NM

American Ambulance Association

John J Russell MD FAAP

American Ambulance Association

Cape Girardeau, MO

American College Of Emergency Physicians

David Lehrfeld MD

Portland, OR

American College Of Surgeons, Committee On Trauma

Mark L. Gestring MD FACS

Chair, EMS Committee, American College of Surgeons Committee on Trauma

Rochester, NY

International Association Of Fire Chiefs

David S. Becker MA Paramedic EFO

EMS Section, International Association of Fire Chiefs

St. Louis, MO

International Association Of Fire Fighters

Robert McClintock FF NRP BSBA

IAFF - Fire-Based EMS Specialist

Washington, DC

International Association of Flight And Critical Care Paramedics

Aaron W. Byrd DHSc MPA NRP FP-C

President, IAFCCP

Cary, NC

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Appendix IV. Acknowledgements 55

National Association of EMS Physicians

John M Gallagher MD FAEMS

Wichita/Sedgwick County EMS System

Wichita, KS

National Association of EMS Educators

Michael G. Miller EdD RN NRP

Creighton University

Omaha, NE

National EMS Management Association

Sean Caffrey MBA FACPE NRP

University of Colorado School of Medicine

Denver, CO

National Registry of Emergency Medical Technicians

Ashish R. Panchal MD PhD

Associate Professor, Department of Emergency Medicine, The Ohio State University Wexner Medical

Center; Research and Fellowship Director, The National Registry of EMTs

Columbus, OH

National Association of Emergency Medical Technicians

Dennis Rowe EMT-P

President, National Association of NAEMT; Director of Government and Industry Relations, Priority

Ambulance Corporation

Knoxville, TN

National Association of State EMS Officials

Kyle Thornton MS, Paramedic

NM EMS Bureau Chief

NASEMSO President-Elect

Albuquerque, NM

Jim DeTienne, Supervisor

Montana EMS & Trauma, DPHHS

Helena, MT

Independent Participants

Leaugeay C. Barnes MS NRP FP-C NCEE

UH- Kapi'olani Community College

Honolulu, HI

Ann Bellows RN NRP Ed D

EMS Program Director, New Mexico State University, Dona Ana Community College

Las Cruces, NM

Richard Kamin MD FACEP

EMS Program Director, UConn Health, Medical Director, CT DPH OEMS

West Hartford, CT

Douglas F. Kupas MD EMT-P FAEMS FACEP

Geisinger Health

Danville, PA

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Appendix IV. Acknowledgements 56

Jules K. Scadden PM

Director of EMS-Dysart Ambulance Service

Dysart, IA

Contributors Skip Kirkwood MS JD NRP CEMSO FACPE

Wake Forest, NC

Gregg Margolis PhD NRP

National Academies of Science Engineering and Medicine

Washington, DC

Michael Touchstone BS FACPE

Fire Paramedic Deputy Chief, EMS Operations

Philadelphia Fire Department

Philadelphia, PA

Technical Writers Kathy Robinson RN

Dan Manz

Project Manager Kathy Robinson RN

Project Coordinator and Graphic Designer Zoe Renfro BA, QAS

Executive Staff Dia Gainor MPA

Elizabeth Armstrong MAM

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Appendix V. References 57

Appendix V. References

1 National Highway Traffic Safety Administration. (2007) National EMS Scope of Practice Model. Washington, DC. Accessed

May 17, 2018 at https://www.ems.gov/pdf/education/EMS-Education-for-the-Future-A-Systems-

Approach/National_EMS_Scope_Practice_Model.pdf.

2 National Highway Traffic Safety Administration. (1996) National EMS Agenda for the Future. Washington, DC. Accessed

May 17, 2018 at https://www.ems.gov/pdf/2010/EMSAgendaWeb_7-06-10.pdf

3 National Highway Traffic Safety Administration (2000) National EMS Education Agenda for the Future : A Systems

Approach. Washington, DC. Accessed May 17, 2018 at https://www.ems.gov/pdf/education/EMS-Education-for-the-Future-A-

Systems-Approach/EMS_Education_Agenda.pdf

4 U.S. Const. amend. XIV. Accessed May 17, 2018 at https://www.gpo.gov/fdsys/pkg/GPO-CONAN-1992/pdf/GPO-CONAN-

1992-10-15.pdf.

5 Dent v. West Virginia, 129 U.S. 114 (1889). Accessed May 17, 2018 at

https://cdn.loc.gov/service/ll/usrep/usrep129/usrep129114/usrep129114.pdf

6 North Carolinas State Board of Dental Examiners v. FTC, 574 U.S. ____ (2015). Accessed May 17, 2018 at

https://www.supremecourt.gov/opinions/14pdf/13-534_19m2.pdf

7 Institute of Medicine of the National Academies (2010) The Future of Nursing Focus on Scope of Practice. Washington, DC.

Accessed May 17, 2018 at http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2010/The-Future-of-

Nursing/Nursing%20Scope%20of%20Practice%202010%20Brief.pdf

8 National Highway Traffic Safety Administration (2005) National EMS Core Content. Washington, DC. Accessed May 29, 2018

at https://www.ems.gov/pdf/education/EMS-Education-for-the-Future-A-Systems-Approach/National_EMS_Core_Content.pdf.

9 National Academies of Science, Engineering, and Medicine. (2007) Emergency Medical Services : At the Crossroads.

Washington , DC. Accessed May 17, 2018 at https://www.nap.edu/read/11629/chapter/5.

10 National Highway Traffic Safety Administration (2011) 2011 National EMS Assessment. Washington, DC. Accessed May 17,

2018 at https://www.ems.gov/pdf/2011/National_EMS_Assessment_Final_Draft_12202011.pdf.

11 National Association of State EMS Officials. (2014) Report to the National EMS Advisory Council on Statewide

Implementation of the Education Agenda. Falls Church, VA. Accessed May 17, 2018 at

http://nasemso.org/EMSEducationImplementationPlanning/documents/Implementing-EMS-Education-Agenda-Report-to-

NEMSAC-23Apr2014-FINAL.pdf.

12 National Registry of Emergency Medical Technicians (2018) National Registry Data, Dashboard, and Maps. Columbus, OH.

Accessed May 29, 2018 at https://www.nremt.org/rwd/public/data/maps.

13 National Highway Traffic Safety Administration. (2017) National EMS Scope of Practice Model Including Change Notices 1.0

and 2.0. Washington, DC. Accessed May 17, 2018 at https://www.ems.gov/pdf/2017-National-EMS-Scope-Practice-

Mode_Change-Notices-1-and-2.pdf.

14 National Highway Traffic Safety Administration (2009). National EMS Education Standards. Washington, DC. Accessed

May 29, 2018 at https://www.ems.gov/pdf/National-EMS-Education-Standards-FINAL-Jan-2009.pdf.

15 The National Traffic and Motor Vehicle and Safety Act of 1966. Pub. L. No. 89-563, 80 Stat. 718 (1966) Accessed May 29,

2018 at https://www.gpo.gov/fdsys/pkg/STATUTE-80/pdf/STATUTE-80-Pg718.pdf.

16 Uniformed Services University College of Allied Health Sciences. (2018) Accessed May 17, 2018 at

https://www.usuhs.edu/cahs.

17 American College of Surgeons Committee on Trauma, American College of Emergency Physicians, National Association of

EMS Physicians, Pediatric Equipment Guidelines Committee -EMSC Partnership for Children, American Academy of Pediatrics.

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(2012) Equipment for Ambulances. Accessed Feb. 5, 2018 at

https://www.facs.org/~/media/files/quality%20programs/trauma/publications/ambulance.ashx.

18 SUNY Empire State College. (2018) Breadth and Depth of Learning. Saratoga Springs, NY. Accessed May 17, 2018 at

https://www.esc.edu/degree-planning-academic-review/evaluator-resources/assessing-learning/breadth-and-depth/

19 34 U.S.C. § 602. The Secretary’s Recognition of Accrediting Agencies (2014) Accessed May 29, 2018 at

https://www.gpo.gov/fdsys/granule/CFR-2014-title34-vol3/CFR-2014-title34-vol3-part602.

20 National Academy of Sciences and National Research Council. (1966) Accidental Death and Disability: The Neglected

Disease of Modern Society. Washington, DC. Accessed May 17, 2018 at https://www.ems.gov/pdf/1997-Reproduction-

AccidentalDeathDissability.pdf.

21 The Emergency Medical Services Systems Act of 1973 Pub. L. 93-154 87 Stat. 594-605. Accessed May 29, 2018 at

https://www.gpo.gov/fdsys/pkg/STATUTE-87/pdf/STATUTE-87-Pg594.pdf.

22 National Academies of Science, Engineering, and Medicine. (2007) Emergency Medical Services: At the Crossroads.

Washington , DC. Accessed May 17, 2018 at https://www.nap.edu/read/11629/chapter/4.

23 Finocchio L, Dower C, Blick N, Gragnola C. (1998) Strengthening Consumer Protection: Priorities for Health Care

Workforce Regulation. San Francisco, CA. Accessed May 17, 2018 at https://healthforce.ucsf.edu/publications/strengthening-

consumer-protection-priorities-health-care-workforce-regulation.

24 National EMS Advisory Council. (2017) Changing the Nomenclature of Emergency Medical Services is Necessary.

Washington, DC. Accessed May 17, 2018 at

https://www.ems.gov/pdf/nemsac/NEMSAC_Final_Advisory_Changing_Nomenclature_EMS.pdf.

25 42 CFR 493, Laboratory Requirements (2011) Accessed June 13, 2018 at https://www.gpo.gov/fdsys/pkg/USCODE-2011-

title42/pdf/USCODE-2011-title42-chap6A-subchapII-partF-subpart2-sec263a.pdf See also, www.cms.gov/CLIA.

26 U.S. Department of Health, Education, and Welfare, Report on Licensure and Related Health Personnel Credentialing

(Washington, D.C.: June, 1971 p. 7) Accessed May 29, 2018 at https://eric.ed.gov/?id=ED061420.

27 NCCA Standards for the Accreditation of Certification Programs, approved by the member organizations of the National

Commission for Certifying Agencies in February, 2002 (effective January, 2003).

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Emergency Medical Services

U.S. Departmentof TransportationNational Highway Traffic Safety Administration

2018 National EMSScope of Practice Model

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